Daily Archives: December 14, 2009

Patient Presentation A 5-year-old male was seen in clinic for his health supervision visit. His mother had no concerns but mentioned that his fingers and toes seemed to peel quite a bit. She stated that this was a chronic problem where he seemed to have thicker skin that would peel. There was no erythema, pruritis or pain. It did not affect his nails or hair and he had not had any localized infections because of the peeling. She said that it was not a real problem but more of an annoyance. The family history and review of systems were non-contributory, and he had no problems with his teeth.

The pertinent physical exam showed a healthy male with normal vital signs and growth parameters in the 75-90%. HEENT showed normal teeth with the secondary left front incisor growing in. He had a normal scalp hair pattern, and had appropriate body hair. His nails were not affected. He had mildly thickened skin on the pads of his fingers and especially of his toes. The ball and heel of the feet were also affected. There was no obvious erythema but there were several uneven areas at the affected edges where tissue divots could be seen. The rest of his examination was normal. The diagnosis of palmar and planter hyperkeratosis was made. As he has no other physical or historical elements that would be consistent with a syndrome, this was thought to be an isolated problem. The physician recommended 10% salicylic acid/emollient preparation to help with the exfoliation. The mother stated that her mother was a licensed cosmetologist and had been using a plant-derived exfoliative agent occasionally which had helped. The mother agreed to try the salicylic acid along with manicure/pedicure care.

Discussion
Palmar and plantar hyperkeratosis is localized or diffuse thickening of the palmar and solar stratum corneum. It can occur in isolation or as part of a generalized disorder such as Sjögren-Larsson syndrome, Conradi’s syndrome, psoriasis, and hypohidrotic ectodermal dysplasia. Treatment includes agents to increase exfoliation such as lactic acid, salicylic acid or urea and soaking and mechanical exfoliation with a pumice stone or scalpel. These are used so tissue build up is decreased. Emollients need to be applied to help prevent fissuring from mechanical stress. Other possible treatments include topical psoralens with ultraviolet A light, topical retinoids or corticosteroids.

Learning Point
The differential diagnosis of desquamating digits includes:

Patient Care
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.

Medical Knowledge
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

Practice Based Learning and Improvement
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

Interpersonal and Communication Skills
17. A therapeutic and ethically sound relationship with patients is created and sustained.

Systems Based Practice
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

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